South American illness baffles scientists as workers succumb to kidney failure at rates unseen anywhere

Jesus Ignacio Flores of Nicaragua started working when he was 16, laboring long hours on construction sites and in the fields of his country's biggest sugar plantation.

Three years ago his kidneys started to fail and flooded his body with toxins. He became too weak to work, wracked by cramps, headaches and vomiting.

On Jan. 19 he died on the porch of his house. He was 51.

Mysterious epidemic: Segundo Zapata Palacios, a sugar cane cutter in Nicaragua, sleeps in a chair beside his wife Emma Vanegas in a hospital bed, three days before he died of a mysterious epidemic leading to chronic kidney disease

His withered body was dressed by his weeping wife, embraced a final time, then carried in the bed of a pickup truck to a grave on the edge of Chichigalpa, a town in Nicaragua's sugar-growing heartland, where studies have found more than one in four men showing symptoms of chronic kidney disease.

A mysterious epidemic is devastating the Pacific coast of Central America, killing more than 24,000 people in El Salvador and Nicaragua since 2000 and striking thousands of others with chronic kidney disease at rates unseen virtually anywhere else.

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Scientists say they have received reports of the phenomenon as far north as southern Mexico and as far south as Panama.

Last year it reached the point where El Salvador's health minister, Dr. Maria Isabel Rodriguez, appealed for international help, saying the epidemic was undermining health systems.

Spreading: Mr Palacios was one of over 24,000 victims of the epidemic in the Pacific coast of Central America since 2000, striking thousands of others with chronic kidney disease at rates unseen virtually anywhere else

Wilfredo Ordonez, who has harvested corn, sesame and rice for more than 30 years in the Bajo Lempa region of El Salvador, was hit by the chronic disease when he was 38. Ten years later, he depends on dialysis treatments he administers to himself four times a day.

'This is a disease that comes with no warning, and when they find it, it's too late,' Mr Ordonez said as he lay on a hammock on his porch.

Many of the victims were manual laborers or worked in sugar cane fields that cover much of the coastal lowlands.

Patients,
local doctors and activists say they believe the culprit lurks among
the agricultural chemicals workers have used for years with virtually
none of the protections required in more developed countries. But a
growing body of evidence supports a more complicated and
counterintuitive hypothesis.

Connections: Many of the victims were manual laborers or worked in the sugarcane fields that cover much of the coastal lowlands

The roots of the epidemic, scientists say, appear to lie in the grueling nature of the work performed by its victims, including construction workers, miners and others who labor hour after hour without enough water in blazing temperatures, pushing their bodies through repeated bouts of extreme dehydration and heat stress for years on end. Many start as young as 10.

The punishing routine appears to be a key part of some previously unknown trigger of chronic kidney disease, which is normally caused by diabetes and high-blood pressure, maladies absent in most of the patients in Central America.

'The thing that evidence most strongly points to is this idea of manual labor and not enough hydration,' said Daniel Brooks, a professor of epidemiology at Boston University's School of Public Health, who has worked on a series of studies of the kidney disease epidemic.

Because hard work and intense heat alone are hardly a phenomenon unique to Central America, some researchers will not rule out manmade factors. But no strong evidence has turned up.

Suffering: Scientists pinpoint its victims' work in construction, mining, and other labor intensive fields working without enough water in blazing temperatures and extreme dehydration and heat stress for years on end

New cause: A previously unknown trigger of kidney disease exemplified by Segundo Zapata Palacios, seen in his last days' care by his wife bathing him, may now be his work's punishing routine

'I think that everything points away from pesticides,' said Dr. Catharina Wesseling, an occupational and environmental epidemiologist who also is regional director of the Program on Work, Health and Environment in Central America. 'It is too multinational; it is too spread out.

'I would place my bet on repeated dehydration, acute attacks everyday. That is my bet, my guess, but nothing is proved.'

Dr. Richard J. Johnson, a kidney specialist at the University of Colorado, Denver, is working with other researchers investigating the cause of the disease. They too suspect chronic dehydration.

'This is a new concept, but there's
some evidence supporting it,' Dr Johnson said. 'There are other ways to
damage the kidney. Heavy metals, chemicals, toxins have all been
considered, but to date there have been no leading candidates to explain
what's going on in Nicaragua ...

'As these possibilities get exhausted, recurrent dehydration is moving up on the list.'

Sacrifice: Mr Palacios, showing his social security card and work ID from the sugar mill, is one of many who will sacrifice their health to work and feed their families, as well as their IDs to others needing the pay from the fields' labor

In Nicaragua, the number of annual deaths from chronic kidney disease more than doubled in a decade, from 466 in 2000 to 1,047 in 2010, according to the Pan American Health Organization, a regional arm of the World Health Organization.

In El Salvador, the agency reported a similar jump, from 1,282 in 2000 to 2,181 in 2010.

Farther down the coast, in the
cane-growing lowlands of northern Costa Rica, there also have been sharp
increases in kidney disease, Dr Wesseling said, and the Pan American
body's statistics show deaths are on the rise in Panama, although at
less dramatic rates.

While some of the rising numbers may
be due to better record-keeping, scientists have no doubt they are
facing something deadly and previously unknown to medicine.

In
nations with more developed health systems, the disease that impairs
the kidney's ability to cleanse the blood is diagnosed relatively early
and treated with dialysis in medical clinics.

Death: Mr Palacios' daughter hugs his body among her siblings, mourning his death after working 20 years at the San Antonio sugar plantation but dying of chronic kidney disease at age 49

In
Central America, many of the victims treat themselves at home with a
cheaper but less efficient form of dialysis, or go without any dialysis
at all.

At a hospital in
the Nicaraguan town of Chinandega, Segundo Zapata Palacios sat
motionless in his room, bent over with his head on the bed.

'He no longer wants to talk,' said his wife, Enma Vanegas.

His levels of creatinine, a chemical marker of kidney failure, were 25 times the normal amount.

His
family told him he was being hospitalized to receive dialysis. In
reality, the hope was to ease his pain before his inevitable death, said
Carmen Rios, a leader of Nicaragua's Association of Chronic Kidney
Disease Patients, a support and advocacy group.

'There's already nothing to do,' she said. 'He was hospitalized on Jan. 23 just waiting to die.'

Zapata Palacios passed away on Jan. 26. He was 49.

Unusual ending: Mr Palacios's body is driven to the cemetery past the sugar cane fields where he worked before succumbing to the disease normally caused by diabetes and high-blood pressure, maladies absent in most of the patients in Central America

Working
with scientists from Costa Rica, El Salvador and Nicaragua, Wesseling
tested groups on the coast and compared them with groups who had similar
work habits and exposure to pesticide but lived and worked more than
500 meters (1,500 feet) above sea level.

Some
30 percent of coastal dwellers had elevated levels of creatinine,
strongly suggesting environment rather than agrochemicals was to blame,
Mr Brooks, the epidemiologist, said. The study is expected to be
published in a peer-reviewed journal in coming weeks.

Mr
Brooks and Dr Johnson, the kidney specialist, said they have seen
echoes of the Central American phenomenon in reports from hot farming
areas in Sri Lanka, Egypt and the Indian east coast.

Jason
Glaser, co-founder of a group working to help victims of the epidemic
in Nicaragua, said he and colleagues also have begun receiving reports
of mysterious kidney disease among sugar cane workers in Australia.

More: Not alone, the number of annual deaths in Nicaragua from chronic kidney disease more than doubled in a decade, from 466 in 2000 to 1,047 in 201 whereas in El Salvador the numbers jumped from 1,282 in 2000 to 2,181 in 2010

Despite
the growing consensus among international experts, Elsy Brizuela, a
doctor who works with an El Salvadoran project to treat workers and
research the epidemic, discounts the dehydration theory and insists 'the
common factor is exposure to herbicides and poisons.'

Nicaragua's
highest rates of chronic kidney disease show up around the Ingenio San
Antonio, a plant owned by the Pellas Group conglomerate, whose sugar
mill processes nearly half the nation's sugar. Flores and Zapata
Palacios both worked at the plantation.

According
to one of Mr Brooks' studies, about eight years ago the factory started
providing electrolyte solution and protein cookies to workers who
previously brought their own water to work.

But
the study also found that some workers were cutting sugar cane for as
long as 9 1/2 hours a day with virtually no break and little shade in
average temperatures of 30 C (87 F).

In
2006, the plantation, owned by one of the country's richest families,
received $36.5 million in loans from the International Finance Corp.,
the private-sector arm of the World Bank Group, to buy more land, expand
its processing plant and produce more sugar for consumers and ethanol
production.

Pesticides: Mr Palacios' wife shows banana trees in their garden they claim show damage from chemicals sprayed over the sugar mill, leading to wonder but no substantial proof yet that the chemicals are connected

In a statement,
the IFC said it had examined the social and environmental impacts of its
loans as part of a due diligence process and did not identify kidney
disease as something related to the sugar plantation's operations.

Nonetheless,
the statement said, 'we are concerned about this disease that affects
not only Nicaragua but other countries in the region, and will follow
closely any new findings.'

Ariel
Granera, a spokesman for the Pellas' business conglomerate, said that
starting as early as 1993 the company had begun taking a wide variety of
precautions to avoid heat stress in its workers, from starting their
shifts very early in the morning to providing them with many gallons of
drinking water per day.

Associated
Press reporters saw workers bringing water bottles from their homes,
which they refilled during the day from large cylinders of water in the
buses that bring them to the fields.

Mr
Glaser, the co-founder of the activist group in Nicaragua, La Isla
Foundation, said that nonetheless many worker protections in the region
are badly enforced by the companies and government regulators,
particularly measures to stop workers with failing kidneys from working
in the cane fields owned by the Pellas Group and other companies.

Family tragedy: Segundo Zapata Palacios, seen in a hanging portrait with his wife Emma Vanegas in 1990, left behind eight children, three of which work in the cane fields and two who already show signs of disease

Many
workers disqualified by tests showing high levels of creatinine go back
to work in the fields for subcontractors with less stringent standards,
he said.

Some use
false IDs, or give their IDs to their healthy sons, who then pass the
tests and go work in the cane fields, damaging their kidneys.

'This is the only job in town,' Mr Glaser said. 'It's all they're trained to do. It's all they know.'

The
Ingenio San Antonio mill processes cane from more than 24,000 hectares
(60,000 acres) of fields, about half directly owned by the mill and most
of the rest by independent farmers.

The
trade group for Nicaragua's sugar companies said the Boston University
study had confirmed that 'the agricultural sugar industry in Nicaragua
has no responsibility whatsoever for chronic renal insufficiency in
Nicaragua' because the research found that 'in the current body of
scientific knowledge there is no way to establish a direct link between
sugar cane cultivation and renal insufficiency.'

Mr
Brooks, the epidemiologist at Boston University, told the AP that the
study simply said there was no definitive scientific proof of the cause,
but that all possible connections remained open to future research.

In
comparison with Nicaragua, where thousands of kidney disease sufferers
work for large sugar estates, in El Salvador many of them are
independent small farmers.

They
blame agricultural chemicals and few appear to have significantly
changed their work habits in response to the latest research, which has
not received significant publicity in El Salvador.

In
Nicaragua, the dangers are better known, but still, workers need jobs.
Zapata Palacios left eight children. Three of them work in the cane
fields.